Nurse prescribers have become “embedded” in practice as their numbers continue to grow, but experts have warned their continued success is at risk from skill loss, outdated practice and the need for more education funding.
An investigation by Nursing Times gauged the progress made by nurse prescribing in recent years as well as looking at the challenges that it now faces. To do this, we collected data on current prescriber numbers and spoke to some of the country’s leading nursing experts in the area.
“Why are we not supporting more nurses to prescribe. Nurses have got the knowledge to educate patients”
The number of nurses that hold a prescribing qualification has grown steadily for the past decade – increasing by around 6% every year – from 43,000 in 2006 to almost 72,000 in 2015.
The gains are mostly down to more independent and supplementary nurse prescribers who, since 2006, have had access to the same drugs as doctors. They have increased in number from just under 10,000 nurses in 2006 to almost 34,000 in 2015.
Meanwhile, the number of district nurses, health visitors and school nurses who hold a community practitioner nurse prescriber qualification – meaning they have access to a restricted formulary – has increased marginally, from 33,000 in 2006 to 38,000 this year.
Experts have said the growth in nurse prescribers with access to the full British National Formulary is down to recognition by employers of the benefits they bring to patient care.
They told Nursing Times further increases in this part of the workforce could benefit patients with long-term conditions, in particular, and help to reduce pressure on GPs.
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But they warned there were a range of challenges that needed to be addressed to ensure the “world class” nurse prescribing in the UK continued.
One academic questioned whether funding being ploughed into the training of physician associates, a new type of clinician popular with government, should instead be diverted to nurse prescribers.
“Why are we not supporting more nurses to prescribe,” said Molly Courtenay, professor in health sciences at Cardiff University and a former nurse.
“Nurses have got the knowledge to educate patients… Plus nurses can prescribe whereas physician assistants can’t,” she said.
She added that it was “ a bit worrying” for nurses that physician assistants were usually being employed at a band 7 – normally the same pay grade as nurse prescribers – when their role did not include prescribing.
But Professor Courtenay said it was encouraging that evidence suggested a high proportion – around 70% – of nurse prescribers were using their qualification in an independent capacity, rather than using it a supplementary way, which included some doctor involvement.
She warned, however, that research had also shown around half of nurses with the community prescribing qualification were not using it in practice at all, due to the formulary being out of date.
“There’s a lot of literature saying that [the formulary] isn’t fit for purpose. It was put together in the ‘90s around 25 years ago,” she said, adding that she was working with the BNF to have it reviewed.
Matt Griffiths, visiting professor of prescribing and medicines management at Birmingham City University, echoed the concerns about outdated practice and skill loss within the community prescribing workforce.
“With school nurses – maybe they could be the right people for prescribing emergency contraception but it’s not on the formulary for them,” he said.
“Steady growth of the workforce is fine, but we need some money enabling people to gain CPD within prescribing”
He added: “Health visitors are very often involved with the care of children with constipation and the NICE guidelines say they should be using macrogols – but they can’t use them because they are not on the formulary list.”
He also said that to maintain the “world class” prescribing practice in the UK, more needed to be done to ensure registrants were accessing continuing professional development.
“Steady growth of the workforce is fine, but we need some money enabling people to gain CPD within prescribing,” he warned.
“That is an issue,” he said. “Some trusts are very anti working with pharmaceutical companies. However, they are often the only ones putting money into education.”
Meanwhile, Teresa Kearney, a recently retired independent prescriber and director of primary care development at South Essex Partnership University Foundation Trust, said problems with recruiting into the nursing workforce as a whole created challenges for increasing prescriber numbers.
She noted nurse prescribers could not be directly trained and that they required many years’ experience before taking on the additional qualification.
“It has never been incentivised in any way,” she said. “It doesn’t have to be financially incentivised – it just needs to be recognised more in terms of the skillset people are developing with respect to being able to deliver holistic and autonomous care.”
“Patient group directions have become an industry and I’m not sure there is the same rigour round a PDG as with a signed prescription”
Barbara Stuttle, chair of the Association for Prescribers – formerly the Association for Nurse Prescribing – said nurse prescribers had “led the way” in non-medical prescribing and were now “very embedded” in healthcare practice.
But she said improvements to practice were still required, such as using patient group directions to supply or administer medicines to a group of patients with a specific condition.
“PGDs have become an industry [in keeping them up to date] and I’m not sure there is the same rigour round a PDG as with a signed prescription,” she said.
“I question whether nurses have had training for supplying drugs under the PGD… My view is we should get rid of PGDs and instead have nurse prescribers so you wouldn’t need the PGD,” she added.